Provider Demographics
NPI:1033196316
Name:WASHBURN, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2698 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8818
Mailing Address - Country:US
Mailing Address - Phone:970-244-2273
Mailing Address - Fax:970-255-1809
Practice Address - Street 1:2698 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8818
Practice Address - Country:US
Practice Address - Phone:970-244-2273
Practice Address - Fax:970-255-1809
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0036397208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47478551Medicaid
CO47478551Medicaid
COC490658Medicare PIN
A03495Medicare UPIN